Sometimes, you have to
look beyond the walls of your ED for solutions to your overcrowding problems,
says Sandy Vecellio, RN, BSN, clinical manager of the ED at Gwinnett
Medical Center in Lawrenceville, GA. And when things really get rough, she advises,
send out an SOS.

Vecellio’s ED is tackling
the root problem of overcrowding and boarding patients by trying to get patients
moving more efficiently through not just her department, but the entire hospital.

The idea is that most of
the backup in her ED is caused not by anything her staff is or isn’t doing,
but by what’s going on in other areas, she explains. When one floor is slow
to discharge patients, those beds aren’t available for new admissions, and eventually
that slowdown will result in patients stacked up in the ED.

So the Gwinnett Medical
Center ED uses a "gridlock page" to alert others that ED overcrowding is getting
out of hand. The basic message is: "Hey! We’ve got patients stacking up here.
Help us by moving your patients out faster."

"When the hospital is full
and we’re holding patients in the ED, we send out a gridlock page that goes
to the beeper of all the managers on the floors," she explains.

Those manager confer with
their charge nurses and look for patients who can be expedited with faster discharges,
Vecellio says. "They might call the physician and ask if this patient can go,"
she says. "With the page, we’re asking them to be more proactive at that point
because they know we’re in a critical situation."

Fax alerts doctors’
offices

At the same time the managers’
beepers are going off, the ED staff also sends a mass fax to physicians’ offices
to alert them to the gridlock. The fax asks that they come to the hospital and
make rounds earlier than usual and try to discharge patients as quickly as possible.

"We get good response from
some physicians, and some don’t respond much at all," Vecellio adds. "That’s
to be expected, but any response helps."

The hospital’s admissions
nurses determine when to initiate the gridlock page. They consider not only
the situation in the ED, but also the hospital’s surgery schedule.

"We have at times needed
almost 50 beds, and patients just had nowhere to go. We’ve had days when patients
were coming out from surgery, and we were already holding 21 patients in the
ED as well," Vecellio continues.

"Any time the ED is holding
three or four patients and we also have surgery patients coming out, they will
go ahead and do the gridlock page," she adds.

Sometimes the admissions
nurses will be proactive and do just a warning page, to alert the other units
that only a few beds are left.

Gwinnett Medical has been
using the gridlock page for about a year employing it about twice a week. The
results have been good, she says.

The ED has almost 90,000
visits per year, and the hospital has only 200 bed, "so our ED volume does not
match our bed capacity," Vecellio notes. "We have to do a lot creative things."

Managers meet to brainstorm

Another strategy for clearing
gridlock in the ED is the hospital’s "intake capacity team," which was formed
four months ago and meets monthly. Prompted by the realization that ED gridlock
doesn’t start in the ED, the hospital created the team to bring together managers
from each treatment area of hospital, a case manager, the director of housekeeping,
and leaders from radiology and the laboratory.

The hospital’s chief of
operations runs the meeting. Vecellio says this situation is better than the
ED manager taking charge, which could breed resentment if other managers thought
the ED leader was trying to boss other departments.

"We all come together and
figure out where we have process issues that need to change," Vecellio points
out.

One problem was beds were
not being cleaned quickly enough. The hospital added positions so they had enough
staff to turn over those beds quickly when the ED needed them, she says. "We
also decided to keep the admission unit open 24 hours a day and increased staff
to make that possible," Vecellio says,

Another change addressed
the cath lab. Cardiology was admitting patients at the end of the day because
the staff of the cath lab already had gone home; the patients had to stay overnight
and wait for the cath lab to open the next day. Because the situation took up
precious bed space, the hospital extended the cath lab hours.

"A lot of things come out
of these meetings that don’t involve changes in the ED, but we change things
in other parts of the hospital that have the effect of freeing up those beds
and moving patients through the ED faster," Vecellio stresses. "You have to
look beyond the ED for solutions."